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Electronic records mandate strains rural hospitals

Carol Weiler, who lives in Sartell and suffers from rheumatoid arthritis, can schedule appointments at her HealthPartners clinic online. She can refill prescriptions and view parts of her medical record via the Web, even at midnight if she feels like it.

Recently, when a worrisome lab result came back, her doctor was able to call her within an hour because the results were transmitted electronically. "This was a Friday at 4 type of thing," says Weiler. "It didn't sit on somebody's desk all weekend"

Joel Karels, who lives in Bigfork, likes that after a check-up at Bigfork Valley Hospital, he can review his electronic medical record with a nurse and receive "a list of what we talked about during the physical, a nice printout in big letters, easy to read."

When Karels broke his leg after regular clinic hours one night, Bigfork's orthopedic surgeon was able to review the situation quickly, from home, before heading in. "He was able to look at my x-ray and give the doctor on call here advice," he says. "He told the people here what they needed to do."

This is the upside of electronic medical records. They bring faster access to test results, allow sharing between clinic and hospital staff and result in fewer handwriting-based mistakes and duplicated tests. They bring greater patient transparency, although that comes with privacy concerns, as well.

Joel KarelsMPR Photo/Jennifer Vogel

Under federal health care reform, hospitals and clinics have to start using electronic records to a "meaningful" degree by 2015 or face escalating penalties. For now there are incentives, but down the line, most underachievers will see Medicare reimbursements trimmed by 1 percent per year up to a possible 5 percent.

Behind the scenes, hospitals are struggling to implement the systems. Rural communities worry the mandate, which can cost millions of dollars to meet, could further strain small-provider finances, forcing them under or leading them to join larger health systems like North and South Dakota-based Sanford Health and Duluth-based Essentia Health.

Medical consolidation is already a trend in the state. Since 1987, according to the Minnesota Hospital Association, 28 rural hospitals have closed. And just during the past 18 months, eight hospitals have gone under the wing of larger systems.

"HOSPITALS ARE VERY PAPER-BASED"

Part of the problem is that hospitals start from so far behind when it comes to electronic records, says Joe Wivoda, a technology consultant for the National Rural Health Resource Center in Duluth. "Hospitals are behind every other industry in information technology," he says.
According to Wivoda, certain departments do use digital systems, like labs, radiology and, of course, billing. But "the priority has never been to put information technology at the point of care where it can impact safety, efficiency and quality."

"Hospitals are very paper-based," he adds.

Wivoda credits federal health care reform with "giving everybody a kick to get them to move in the right direction." But he also says it can take years to get an electronic records system up and running. "A lot of hospitals are going to run into the fines," he says. "It's going to be probably half or more who won't be able to reach it in time."

Rural communities face special challenges, he says. "Financing is an issue. It's not just the hardware and software, but also the implementation process. There will be a productivity loss at first." Among the 102 hospitals counted as rural by the Minnesota Hospital Association in 2009, 59 percent operated with net margins of less than 5 percent, and a quarter were in the red.

Al VogtPhoto courtesy Al Vogt

Even if hospitals and clinics do get the money to buy a system, says Wivoda, "There is the matter of finding the help to do it. Most rural hospitals don't have many, if any, IT people, let alone a health care IT person. There is a massive shortage there."

The federal government has awarded grants to help with the implementation of electronic records. The group charged with helping in Minnesota, called Key Health Alliance, is a collaboration of the College of St. Scholastica in Duluth, the National Rural Health Resource Center, and Stratis Health, a nonprofit that monitors the quality of Medicare services in the state. Key Health received more than $20 million to assist clinics and hospitals in Minnesota and North Dakota.

"We don't provide equipment," says Susan Severson, Stratis' director of health information technology services. "We have more of a consulting perspective." In order to achieve what is known as "meaningful use" — specific, practical objectives that must be met — Key Health helps primary care providers choose the most appropriate software and adjust their workflows to accommodate it.

Choosing software can be a mystifying endeavor, given aggressive software makers pushing their wares with fancy demonstrations. "We're very specific about guiding them through the selection process," says Severson, who adds that Key Health is "vendor neutral" but not "vendor dumb."

"We make sure they don't go to demos until they're well-seasoned and know what they're looking for," she says. "You don't go to a car lot and say, 'This is pretty.' They need to be savvy shoppers."

This is especially important, Severson adds, because the software can be programmed to suggest treatment protocols used by physicians in decision making. "They provide some clinical decision support that's pretty suggestive," says Severson. "Part of the review process is to make sure the templates are usable and agree with the philosophy of their practice." Key Health staff will lead providers through exercises to determine how they are going to treat their top five diagnoses, for example, to make sure the software reflects these protocols.

Software makers are struggling to keep up with demand created by federal health care reform, meaning that sometimes their products don't live up to the demos or technological support falls short. "Most of the larger vendors have several hundred job openings for implementation," says Wivoda. "It used to be that if you bought an electronic health record, you would get six to 12 weeks of on-site time. Now you get two weeks. It's pretty tough."

Still, Minnesota is ahead of the nation when it comes to implementing electronic health records. "Maybe 5 percent of hospitals in the country are at a point where they have reached meaningful use," says Wivoda. "In Minnesota, that's closer to 10 percent. Clinics are further along, probably 20 to 30 percent in the country. Minnesota might be a little bit higher than that."

BANDING TOGETHER TO SAVE MONEY

Some of that success can be attributed to a Duluth-based network of outstate hospitals called SISU, which one fan suggests is "Finnish for chutzpah." The consortium provides its members technical equipment and support and saves money through group purchasing and volume discounts.

"A lot of pricing is based on bed size or revenue," says Jodi Nelson, SISU's chief operations officer. "These rural hospitals pay more. This was a means for us to pull together users for purchasing power and licensing agreements and to leverage the numbers."

Informally started in 1982, SISU became official in 1997. Its 22 full and associate members range from Regina Medical Center in Hastings to Cook County North Shore Hospital & Care Center in Grand Marais. The organization, which operates as a non-profit, embraces system hospitals and independents alike.

It's all but impossible for a hospital to go it alone on electronic medical records, explains Nelson. "It's about cost and resources. Partnering with other organizations allows them to pool together and make more headway. The savings are incredible."

"Without networks, [independent] rural hospitals will not exist in the future," says Terry Hill, executive director of the Rural Health Resource Center. "Either you have to be part of a network or part of a system." When the Center and the University of Minnesota surveyed rural health networks nationally in 2009, 15 percent said their biggest achievement was "survival/stability," up from 4.5 percent in 2000.

Hill calls SISU, "The most advanced health IT network in the country."

One SISU member, FirstLight Health System in Mora, was the first critical access hospital (a federal designation for rural hospitals with 25 beds or fewer) in the country to reach a level six out of seven on the electronic records adoption scale.

"The consortium is the primary basis for our success," says FirstLight CEO Randy Ulseth, noting that the hospital started the conversion process almost a decade ago. "Second, there has been an immeasurable desire by our staff to move things forward. The nurses took on extra work. The physicians had more work put on their shoulders. Everybody took it on. Some kicking and screaming, but most took it on as a challenge. And obviously, we were successful."

Another SISU member making advances on electronic health records is the 14-bed Cook Hospital in Cook, northwest of Duluth. CEO Al Vogt, who also serves as president of the Minnesota Wilderness Healthcare Coalition, says implementing the records can feel like a never-ending task. "There is not enough money in the world," he says. "I'm not sure that even God's bank has enough money for electronic medical records. Are we working on it? We're working ourselves crazy."

"Eighty percent of our capital budget every year goes toward implementing another aspect of EMR," says Vogt, who expects his hospital to reach meaningful use by 2012. "The investment is huge for a small outfit like ours. I'm talking hundreds and hundreds of thousands of dollars."

Cook has been working on electronic records since the mid 1990s, Vogt says. "It's a long haul. I don't think there is enough time in my career to finish this project. I'll be rolling down the hallway in a wheelchair, hitting machines with my cane, saying 'Put in another module.'"

"In the Wild West of health care reform," he adds, "you never know which gun slinger is going to come to town. You walk down the street and hope you can avoid the gunfire." Without SISU, he says the cost of electronic records might have run in the millions. "It has saved us huge amounts of money. I couldn't afford a systems administrator on my own. But with SISU I can."

The crucial point to remember in the scrum of the larger health care debate, says Vogt, is that rural hospitals must continue to exist. Financially, Cook is doing "okay," he says. But, "Say healthcare reform drives Cook Hospital under. People will have to drive up to 100 miles for health care. Is that the right thing to do? I don't believe it is."